Late reoperations after repaired acute type A aortic dissection

Three-year outcomes of the Dissected Aorta Repair Through Stent Implantation trial

OBJECTIVE

The study objective was to evaluate the clinical and radiographic outcomes of the Ascyrus Medical Dissection Stent in a prospective, nonrandomized, international study (Dissected Aorta Repair Through Stent Implantation) of patients with acute DeBakey type I aortic dissection.

METHODS

The Ascyrus Medical Dissection Stent was used in combination with the standard surgical management of acute DeBakey type I aortic dissection I to treat patients with (56.5%, 26/46) and without (43.5%, 20/46) preoperative clinical and radiographic malperfusion. All patients had a primary entry tear in the ascending aorta, and 97.8% (45/46) were treated with a hemiarch repair. Median follow-up was 3 years.

RESULTS

All 47 patients underwent emergency surgical repair with successful Ascyrus Medical Dissection Stent implantation. One patient was excluded from analysis due to use in iatrogenic dissection. Overall mortality at 30 days and 3 years was 13.0% (6/46) and 21.7% (10/46), respectively. Overall new stroke rate at 30 days was 15.2% (7/46). No devices were explanted at any time during the 3-year median follow-up. At 3 years, the total aortic diameter in zones 0, 1, and 2 decreased or remained stable in 91.7%, 72.7%, and 75.0%, respectively. The false lumen was completely or partially thrombosed in 90.5% in zone 0, 60.0% in zone 1, and 68.2% in zone 2 at 3 years.

CONCLUSIONS

The use of the Ascyrus Medical Dissection Stent in the treatment of acute DeBakey type I aortic dissection I holds promise as a simple technology that enables repair of the aortic arch and proximal descending aorta, while promoting positive aortic remodeling. Ongoing follow-up of the Dissected Aorta Repair Through Stent Implantation trial will provide long-term, prospective, clinical outcomes and radiographic data on positive remodeling of the aortic arch.

Endovascular arch repair of anastomotic aneurysm and pseudoaneurysm in patients after open repair of the ascending aorta and aortic arch: a case series

OBJECTIVES

The aim of the study was to investigate the outcomes of branched endovascular arch repair (b-TEVAR) with a custom-made double- or triple-branched arch endograft in patients with distal anastomotic aneurysms after open repair of the ascending aorta or proximal arch replacement.

METHODS

Retrospective analysis was conducted of all consecutive patients with anastomotic aneurysms after open surgical repair involving the ascending aorta and/or aortic arch treated with b-TEVAR. All patients were treated with a custom-made double or triple inner-branched arch endograft. Study end points were technical success, 30-day and follow-up mortality/morbidity and re-interventions.

RESULTS

Between 2018 and 2022, 10 patients were treated with custom-made double- or triple-branched thoracic endovascular aortic repair due to anastomotic aneurysms after open ascending aorta and/or proximal aortic arch replacement. Eight patients received a triple and 2 a double arch-branched endograft. Eight cases were performed electively and 2 urgently for contained rupture. Technical success was achieved in 9 cases (90%). All elective patients survived. Two patients treated due to contained ruptures expired. Within 30 postoperative days, 1 transient ischaemic attack occurred. No early endograft-related re-interventions were necessary. The median follow-up was 20 months. One patient died 2 months after discharge due to sepsis caused by pneumonia. No further deaths or endograft-related re-interventions were observed.

CONCLUSIONS

Endovascular aortic arch repair with double or triple inner-branched arch endograft for anastomotic aneurysms after open ascending and/or proximal arch replacement is technically feasible and a promising alternative in a patient cohort unfit for surgery.

Aortic Reoperation After Prior Acute Type A Aortic Dissection Repair: Don't Despair the Repair

BACKGROUND

There is paucity of data regarding reoperation after acute type A aortic dissection (ATAD) repair.

METHODS

From October 2006 to March 2022, 75 patients received 123 reoperations after ATAD (proximal, n = 17; distal, n = 103; and both, n = 3) utilizing redo sternotomy (RS, n = 68), left thoracotomy (LT, n = 44), and endovascular approach (TEVAR, n = 11). The axillary artery cannulation was utilized in 97.1% of the RS cases. A classic elephant trunk technique was used as a 2-staged procedure for distal pathology. Most LT repairs (95.5%) were completed above the celiac axis.

RESULTS

Index ATAD repairs were predominantly ascending/hemiarch repair (73.3%). The median duration from the index repair was 2.0 years. Most reoperations were elective procedures (82.1%). Hospital mortality was 2.4% (RS, 1.5%; LT, 4.5%; TEVAR, 0%), and the stroke rate was 1.6%. There was no spinal cord ischemia. The 5-year overall survival and freedom from aortic mortality or procedure were 85.2% ± 5.6% and 80.6% ± 6.1%, respectively. There were 7 distal reinterventions (prior TEVAR, n = 3; prior LT, n = 4). Two patients required LT repair after prior TEVAR and 3 patients received infrarenal aortic repair after prior LT repair. Computed tomography after completion of the distal repair (n = 45) showed an increase of distal aorta at each level as follows: celiac axis 1.2 mm/y; renal artery 1.0 mm/y; and terminal aorta 1.2 mm/y.

CONCLUSIONS

Reoperation after ATAD repair can be safely performed as an elective procedure at experienced centers. Staged distal interventions utilizing classic elephant trunk insertion and open repair above the celiac axis showed durable outcomes.

Outcomes of reoperation for total arch replacement combined with frozen elephant trunk after previous cardiovascular surgery

BACKGROUND

Aortic arch replacement(TAR) combined with frozen elephant trunk (FET) technique is a high-risk operation after previous cardiovascular surgery. The aim of the study was to review our strategy and outcomes in this cohort.

METHOD

Data were reviewed for patients who underwent TAR combined with FET after previous cardiovascular surgery from January 2010 to December 2020. The patients were divided into elective group and non-selective group.

RESULTS

63 eligible patients were divided into elective(n = 44) and non-elective(n = 19) groups. The interval between two operations was shorter in non-elective group than elective groups (P = 0.001). The indication for reoperation was different in two groups (P = 0.000), however, the type of reoperations has no differences. Cardiopulmonary bypass time was shorter in elective group than non-elective group (P = 0.000). The over-all 30-day mortality rate was 17.5%, and it was higher in non-elective group (P = 0.013). The 24h drainage increased in non-elective group (P = 0.001) as well as re-explore rate for bleeding (P = 0.022). Postoperative hospital stay prolonged in non-elective group (P = 0.002). However, rates of survival without further aortic events were 72.3 ± 7.1% in elective group, 72.9 ± 13.5% in non-elective group at 5 years, respectively (P = 0. 955).

CONCLUSION

Reduced 30-day mortality and shortened post-operative hospital stay was observed in elective group, however, long-term survival rate without reintervention were not affected.

Limited Distal Repair Results in Low Rates of Distal Events Following Surgery for Acute Type A Aortic Dissection

To investigate mortality and reoperation rates following limited distal repair after acute type A aortic dissection (ATAAD) at a single medium volume institution. We analyzed all patients that underwent limited distal repair (ascending aortic or hemiarch replacement) following ATAAD between January 1998 and April 2020 at our institution. During the study period, 489 patients underwent ATAAD surgery, of which 457 (94%) underwent limited distal repair with a 30-day mortality of 12.9%. Among 30-day survivors, late follow-up was 97.7% complete with a mean follow-up of 6.0 ± 5.5 years. In all, 50 patients (11%) required a reoperation during the study period at a mean of 3.4 ± 3.4 years after initial repair, with a 30-day mortality of 12%. An aortic reoperation was required in 4.1 (2.0-6.1)%, 10.3 (7.1-13.6)%, 15.1 (10.9-19.4)%, and 18.0 (13.0-22.9)% of patients at 1, 5, 10, and 15 years. A distal reoperation was required in 3.0 (1.2-4.7)%, 8.0 (5.1-10.9)%, 10.3 (6.8-13.8)%, and 12.4 (8.2-16.5)% of patients and 4.4 (2.3-6.4)%, 10.4 (7.1-13.7)%, 13.9 (9.8-18.0)%, and 16.9 (12.0-21.9)% of patents had a distal event at 1, 5, 10, and 15 years, respectively. Limited distal repair with an ascending aortic or hemiarch replacement was associated with acceptable survival and rates of reoperations and distal events. Limited distal repair is a safe and feasible standard approach to ATAAD surgery at a medium-volume center.

Imaging surveillance for complications after primary surgery for type A aortic dissection

Acute type A aortic dissection (ATAAD) is a life-threatening condition that requires emergency surgery to avert fatal outcome. Conventional surgical procedures comprise excision of the entry tear and replacement of the proximal aorta with a synthetic vascular graft. In patients with DeBakey type I dissection, this approach leaves a chronically dissected distal aorta, putting them at risk for progressive dilatation, dissection propagation and aortic rupture. Therefore, ATAAD survivors should undergo serial imaging for evaluation of the aortic valve, proximal and distal anastomoses, and the aortic segments beyond the distal anastomosis. The current narrative review aims to describe potential complications in the early and late phases after ATAAD surgery, with focus on their specific imaging findings.

Mid-Term Outcomes of a Hybrid Approach Involving Open Surgery Plus TEVAR of the Descending Aorta in the Treatment of Complex Type A Dissection

OBJECTIVES

Type A aortic dissection with true lumen collapse and malperfusion downstream is associated with a devastating prognosis. This study compares the clinical outcomes of two operative strategies for this disease: hybrid approach of ascending aorta (and hemiarch replacement) supplemented with retrograde stenting of the descending aorta (thoracic endovascular aortic repair [TEVAR]) and standard ascending aorta (and hemiarch) replacement without stent placement.

METHODS

From January 1, 2016 to December 31, 2019, 81 patients with type A aortic dissection were studied. The hybrid technique was applied in 30 patients (group 1), while 51 patients received standard surgical repair (group 2). Patient demographics, clinical and operative findings, postoperative outcome, follow-up interventions, and mid-term survival were analyzed.

RESULTS

Baseline characteristics were similar among the groups, except that more preoperative malperfusion was evident in group 1. The postoperative incidence of visceral malperfusion (0 vs. 15.7%, p = 0.02) and low cardiac output syndrome requiring extracorporeal membrane oxygenation support (3.3 vs. 19.6%, p = 0.04) was significantly less in group 1. In-hospital mortality was also significantly lower in group 1 as in group 2 (13.3 vs. 33.3%, p = 0.04). At follow-up, the need for secondary endovascular stenting (3.3 vs. 7.8%, p = 0.65) and surgical aortic reintervention (6.7 vs. 2.0%, p = 0.55) was comparable. One-year, 2-year, and 3-year survival rates were 83.3, 83.3, and 62.5% in group 1, and 58.7, 58.7, and 52.6% in group 2 (p = 0.05), respectively.

CONCLUSION

The combination of open surgical replacement of the ascending aorta (and hemiarch) with TEVAR of the descending aorta for true lumen compromise is a feasible treatment option for patients with type A aortic dissection and is associated with a better perioperative outcome and improved mid-term survival rate.

Aortic Pseudoaneurysm After Type A Aortic Dissection: Results of Conservative Management

Aortic pseudoaneurysms after acute Type A aortic dissection (ATAAD) repair have been reported as high as 10-24% and surgical treatment is usually recommended. The objective of this article is to examine the safety and efficacy of a conservative approach to aortic pseudoaneurysm and to compare this approach to standard surgical treatment. We retrospectively examined 39 patients who had an aortic pseudoaneurysm after ATAAD surgery in order to examine outcomes (baseline characteristics, presentation and freedom from aortic events and mortality). We initially identified 31 patients treated conservatively (CT). After close follow up, 5 of them were operated so 13 patients were treated surgically (ST) and analyzed at a long-term follow-up while 26 were in the conservative group. Mean follow- - up of the whole cohort was 7.9 ± 5.9 years. The freedom from aortic-related mortality at 1, 5, and 10 years was 100%, 83.3% and 72.9% for the ST group and 95.8%, 77.3%, and 77.3% for the CT group (P = 0.35). A conservative approach to aortic pseudoaneurysms could be justified in asymptomatic patients. A close follow-up by a dedicated aortic clinic is mandatory so that patients are referred for surgery when necessary.

Time is of the essence: where can we improve care in acute aortic dissection?

OBJECTIVES

In acute aortic dissection type A various components of the diagnostic and logistic pathways may affect the time to definitive treatment. This study aimed to characterize these components and to identify factors delaying the optimal management within our institutional referral network.

METHODS

Between January 2017 and January 2020, 96 consecutive patients with classical aortic dissection type A were admitted (28%) or referred (72%) to our tertiary care centre and analysed retrospectively. Data are presented as medians (25th-75th quartile).

RESULTS

Median age was 66 years (56-74), 63% were male. Most of the patients were primarily admitted to a cardiology department (40%), whereas about a fourth were admitted to departments for internal medicine (26%) and general surgery (27%). The median interval from the onset of symptoms to hospital admission was 2.1 (1-4.4) h. From admission to confirmed diagnosis it took 2.1 (0.6-9.5) h and the median interval from confirmed diagnosis to admission at our specialized tertiary care aortic centre was 1.5 (0.9-2.4) h. Following admission to our centre, 1.1 (0.5-1.9) h passed until the induction of anaesthesia and 0.8 (0.0-1.1) h until the start of surgery. The total interval from the onset of symptoms to the start of surgery was 7.6 h (5.1-12.3).

CONCLUSIONS

The marked variability of the time from symptoms to diagnosis at any medical facility demonstrates the importance of awareness in the optimization of the treatment of acute aortic dissection type A.

Outcomes of long versus short stent cronus hybrid prosthesis in type A aortic dissection: A single centre experience

OBJECTIVES

The frozen elephant trunk (FET) technique has become an important tool in the treatment of acute type A aortic dissection. The aim of this study was to evaluate the effect of long FET on spinal cord injury (SCI) and distal aortic remodeling after acute type A aortic dissection based on clinical and radiological outcomes.

METHODS

From January 2018 to November 2019, 158 patients (mean age 51.8 years [range: 32-78 years], 88.6% male) with acute type A aortic dissection were treated by FET with 100 mm (n = 113) or 150 mm (n = 45) open hybrid stent graft prosthesis. Patients were divided into two groups according to the length of FET. The clinical and radiological outcomes of the patients were reviewed retrospectively.

RESULTS

Postoperative outcomes did not differ significantly: in-hospital mortality (9.7% vs. 6.7%, p = .758) and SCI (5.3% vs. 2.2%, p = .674). Aortic remodeling, which was evaluated by aortic diameter, true lumen diameter, false lumen (FL) diameter and the rate of FL complete thrombosis, was more positive in long FET group in the descending thoracic aorta during the follow-up period. At the abdominal level, there was no statistically significant difference between the two groups.

CONCLUSIONS

The long version of FET does not increase the risk of SCI in patients with acute type A aortic dissection. The application of long FET can achieve better results in terms of remodeling of the thoracic aorta in the short- and medium-term follow-up.

Relationship Between Heart Rate at Discharge and Long-Term Outcomes of Surgically Treated Patients With Type A Acute Aortic Dissections

BACKGROUND

Resting heart rate (HR) at discharge is an important predictor of mortality after acute myocardial infarction. However, in patients with Stanford type A acute aortic dissections (TA-AADs), the relationship between HR and long-term outcomes is unclear. Therefore, this relationship was investigated in the present study.Methods and Results:Surgically treated consecutive patients with TA-AAD (n=721) were retrospectively categorized according to HR quartiles, recorded within 24 h before discharge (<70, 70-77, 78-83, and ≥84 beats/min). The study endpoints included aortic aneurysm-related deaths, sudden deaths, aortic surgeries, and hospitalizations for recurrence of acute aortic dissections. The mean (±SD) patient age was 65.8±13.0 years. During a median observation period of 5.8 years (interquartile range 3.9-8.5 years), 17.2% of patients (n=124) experienced late aortic events. Late aortic surgery was performed in 14.0% of patients. After adjusting for potential confounders, including β-blocker use, HR at discharge remained an independent predictor of long-term aortic outcomes. Patients with discharge HR ≥84 beats/min had a higher risk (hazard ratio 1.86; 95% confidence interval 1.06-3.25; P=0.029) of long-term aortic events than those with HR <70 beats/min; the cumulative survival rates were similar among the groups (log-rank, P=0.905).

CONCLUSIONS

In surgically treated patients with TA-AAD, HR at discharge independently predicted long-term aortic outcomes. Consequently, HR in patients with TA-AAD should be optimized before discharge, particularly if the HR is ≥84 beats/min.

A decade of surgical therapy in an all-comer cohort with type A aortic dissection

BACKGROUND

We reported on a decade of aortic surgery for type A aortic dissection to assess surgical techniques employed and outcomes over time in an all-comer analysis of a mid-size university cardiosurgical center.

METHODS

From 2009 to 2018, 283 patients (189 males and 94 females, mean age 62 years, range 30-85 years), who underwent surgical therapy for type A aortic dissection in our institution were included in a retrospective statistical analysis.

RESULTS

Among all the patients, 55.5% of them were hemodynamically stable, 10.3% came in intubated. A neurological deficit was present in 18.9% of cases, extremity malperfusion was noted in 17.4%, and abdominal malperfusion detected in 8.2%. The extent of the aortic dissection corresponded to DeBakey type I in 88% of cases, a thoracoabdominal involvement was seen in 64%. In 51.9% of patients, only the ascending aorta replaced, another 40.6% of patients had proximal arch replacement too. A separate stent placement into the descending aorta was achieved in 13.4% of patients, during surgery (5.7%) or thereafter (7.7%). Overall survival to discharge was 79.5%. Most frequent complications were stroke and paralysis (15.2%), but only visceral malperfusion (OR 9.0) and heart failure mandating ECMO therapy (OR 29.5) were associated with significantly increased mortality.

CONCLUSIONS

Surgery for type A aortic dissection is still challenging. Along with the refinement of surgical techniques, the indication for the various procedures has moved from a simplified general strategy to a more individualized concept.

25 Years' Experience with Redo Operations in Cardiac Surgery-Third-Time Sternotomy Procedures

BACKGROUND

 Over the years, open heart surgery has become more complex, and especially reoperative surgery, more demanding. The risk of third-time or more sternotomy procedures is unclear.

METHODS

 We reviewed our institutional experience of 25 years based on two generations of cardiac surgeons in a German university medical center to document frequency, outcome, and complications of the various types of open heart procedures.

RESULTS

 Overall, we included 104 patients with a mean age of 64 ± 13 years. The EuroSCORE II (European System for Cardiac Operative Risk Evaluation) calculated an average mortality risk of 15.7 ± 15.4%. Subgroup comparison of isolated coronary artery bypass grafting (CABG), aortic valve replacement, and mitral valve replacement procedures did not delineate significantly different risk profiles except for the incidence of acute myocardial infarction, which was present in every second patient (53.3%) scheduled for CABG surgery. The time interval to previous surgery was 4.7 ± 6.3 years on average. Most frequent surgical procedures were valve operations, which were accomplished in 72 patients (69.2%), whereas coronary bypass surgery was performed in 23 patients (22.1%) only. Combined procedures were performed in 27 patients. Complex aortic arch replacement with a frozen elephant trunk procedure was necessary in six patients. Overall, 30-day survival was 81.7%.

CONCLUSION

 In conclusion, third-time and more sternotomy procedures offer acceptable outcome and should therefore be considered in appropriate patients.

Efficacy of cardiovascular surgery for Marfan syndrome patients: a single-center 15-year follow-up study

Background

Most Marfan syndrome (MFS) patients have thoracic aortic diseases which is the major cause of death. The aim of the study is to analyze the impact of different surgical procedures on prognosis of MFS patients.

Methods

We retrospectively analyzed the results of hospitalization and long-term follow-up of MFS patients who underwent surgical intervention in our center.

Results

Of the 135 MFS patients, 11 died during hospitalization (8.1%). There were no statistical differences in in-hospital mortality between the proximal surgery group and the distal surgery group (P=0.11). Compared to patients who underwent proximal aortic surgery, patients who underwent arch and distal surgery were more likely to have postoperative respiratory dysfunction (P=0.008). The type of surgical procedure was not associated with the incidence of complications during hospitalization. Pre-surgical New York Heart Association (NYHA) Functional Classification IV (P=0.047), EF <50% (P=0.047), pre-surgical atrial fibrillation (P=0.042), and the injury of dissection propagating onto coronary arteries (P=0.02) were independent risk factors for post-surgical mortality. After 15 years of follow-up, there were no deaths in the David group, while the 15-year survival rate for patients in the Bentall group was 73%±13.5%, and 71%±13.9% for patients in the arch surgery group (P=0.42). The probability of patients in the David group not requiring re-surgery after 15 years was 58.9%±20%, while it was 58.7%±12.1% for patients in the Bentall group, 71.5%±10.5% for patients in the Bentall + Arch group, and 12.5%±11.7% for patients in the Arch + Stent group (P=0.007).

Conclusions

The David procedure was the most beneficial and had the highest long-term patient survival rates.

Trans-catheter closure of aortic anastomosis leak after aortic replacement: classifications and techniques

Background

Aortic anastomotic leak (AAL) is knotty complication after aortic replacement. We aimed to evaluate the feasibility and efficacy of the techniques of trans-catheter AAL closure as well as to evaluate the impact of the new classification on the interventional closure.

Methods

From October 2015 to November 2017, 20 consecutive high surgical risk patients (mean age 47±12 years, 13 males) were referred to our center for trans-catheter closure AALs. Due to the variation of leak, we therefore developed a new-classification based on transesophageal echocardiography (TEE) and computed tomography angiography (CTA) assessments: type I: aorta-to-right atrium fistula, n=6; type II: pseudoaneurysm induced by a suture line dehiscence, n=4; type III: patency of the false lumen in aortic dissection, n=10. Outcomes were analyzed by assessing TEE and CTA in different types of AALs.

Results

Successful closure was accomplished in 17 subjects (85%). The severity of AAL reduced significantly in 15 patients (88%); two patients required a second procedure. At follow-up, we found that in type I, the right atrium systolic pressure reduced (from 25.3±4.1 to 7.0±1.2 mmHg) with the improved NYHA (3.5±0.6 vs. 1.0±0.0), the diameter of pseudoaneurysm significantly decreased (5.0±1.8 to 2.0±1.8 mm) in type II, and complete thrombosis was achieved in all type III patients.

Conclusions

Trans-catheter closure of AAL displays satisfactory results even in those defined as high-risk patients, and it could be considered be a viable alternative approach. New classification is helpful in decision-making.

Is total arch replacement associated with an increased risk after acute type A dissection?

Background

The surgical strategy for acute type A aortic dissection (AADA) usually consists of reconstruction of the tear-lesion in the affected part of the ascending aorta. The optimal strategy either to replace the ascending aorta (AAR) or to replace the ascending aorta and the total aortic arch (TAAR) is still under debate. Our study compares the 30-day mortality between AAR and TAAR in AADA surgery.

Methods

In this retrospective observational study, we analysed a total patient cohort of 339 patients who underwent surgery for AADA from January 2001 until December 2016. A propensity score-matched analysis between the AAR- and the TAAR-group with 43 patients for each subgroup was subsequently carried out. A multivariable analysis was performed to identify risk-factors for the 30-d-mortality. The 30-day mortality was defined as the primary end-point and long-term survival was the secondary endpoint.

Results

In 292 (86.1%) patients AAR and in 47 (13.9%) patients TAAR was performed for emergent AADA. Patients were older (P=0.049) in the AAR group. The median log Euro-SCORE was 25.5% (12.7; 41.7) for AAR and 19.7% (11.7; 32.2) for the TAAR patient cohort (P=0.12). Operative time, cardiopulmonary bypass- (CPB), cross-clamp- and ischemic time were significantly longer in the TAAR group (P<0.001). The overall 30-day mortality-rate was 17.7% (n=60) but was not significantly different between the two groups (P=0.27). Forty-nine (16.8%) patients died in the AAR and 11 patients (23.4%) in the TAAR group. After propensity-score matching, no difference in mortality was seen between the subgroups as well (P=0.44). Multivariable analysis identified the Euro-SCORE, long operation-time, postoperative dialysis and arrhythmia and administration of red blood cell concentrates as risk factors for 30-day mortality, but not for TAAR versus AAR.

Conclusions

The therapeutic goal in AADA surgery should be the complete restoration of the aorta to avoid further long-term complications and re-operations. Though 30-day mortality and postoperative co-morbidity for AAR are comparable to those in TAAR after treatment of AADA in our analysis, decision-making for the surgical strategy should weigh the operative risk of TAAR against the long-term outcome.

Repair of residual aortic dissections with frozen elephant trunk technique

Background

In this study, we present our mid-term results of reoperation with the frozen elephant trunk procedure due to patent false lumen-related complications in patients previously undergoing supracoronary aortic repair for acute type A aortic dissection.

Methods

Between January 2013 and September 2018, a total of 23 patients (17 males, 6 females; mean age 51.5±9.7 years; range, 30 to 67 years) who underwent ascending aortic replacement due to type A aortic dissection and, later, frozen elephant trunk procedure for residual distal dissection were included. For diagnostic purposes and follow-up, computed tomography angiography was performed in all patients, and both re-entry and aortic diameters were evaluated. Echocardiography was used to evaluate cardiac function and valve pathologies.

Results

The Ishimaru zone 0 (n=11, 47.8%), Ishimaru zone 1 (n=1, 4.3%), Ishimaru zone 2 (n=4, 17.4%), and Ishimaru zone 3 (n=7, 30.4%) were used for frozen elephant trunk stent graft fixation. The mean duration of cardiopulmonary bypass and antegrade selective cerebral perfusion was 223.9±71.2 min and 88.9±60.3 min, respectively. In-hospital mortality was 13%, while there was one (4.3%) aortic-related death and four (17.4%) re-interventions during follow-up.

Conclusion

Early repair should be considered in the presence of persistent dissections due to alarmingly high mortality rates of reoperations. Reoperation with the frozen elephant trunk procedure has acceptable results and the decision of the procedure to be performed should be based on preoperative risk factors of the patient.

Midterm Outcomes of the Dissected Aorta Repair Through Stent Implantation Trial

BACKGROUND

The intimal flap at the distal aortic anastomosis after standard aortic dissection repair creates distal anastomotic new entry, leading to false lumen (FL) pressurization and true lumen (TL) collapse and resulting in increased mortality, malperfusion, aortic growth, and reinterventions. The Ascyrus Medical Dissection Stent (AMDS; Ascyrus Medical, Boca Raton, FL) is a hybrid prosthesis that seals and depressurizes the FL at the distal anastomosis while expanding and pressurizing the TL.

METHODS

The Dissected Aorta Repair Through Stent Implantation trial is a prospective, nonrandomized, international type A dissection trial where patients with acute DeBakey I dissections were enrolled between March 2017 and January 2019. Forty-seven patients were enrolled (median age, 62.5; 67.4% men) with a median follow-up of 631 days.

RESULTS

All patients underwent emergent surgical repair with successful AMDS implantation. One patient was excluded because of use in iatrogenic dissection. Overall mortality at 30 days and 1 year was 13.0% (6/46) and 19.6% (9/46), whereas new strokes occurred in 6.5% (3/46). Over 95% of vessel malperfusions resolved because of AMDS-induced TL expansion, including 3 patients with preoperative paralysis. Positive remodeling of the aortic arch occurred in 100% of cases with complete obliteration or thrombosis of the FL in 74%. In the proximal descending thoracic aorta positive remodeling occurred in 77% and complete obliteration or FL thrombosis in 53% of cases.

CONCLUSIONS

AMDS facilitates single-stage management of malperfusion and induces positive remodeling of the aortic arch through effective sealing of the distal anastomotic FL, depressurization of the FL with expansion, and pressurization of the TL. Importantly the use of AMDS is safe and reproducible.

A meta-analysis of combined proximal stent grafting with or without adjunctive distal bare stent for the management of aortic dissection

BACKGROUND

The efficacy and safety of placement of a proximal covered stent graft combined with a distal bare stent are controversial because of the lack of evidence. This systematic review and meta-analysis compared the outcomes of combined proximal covered stent grafting with distal bare stenting (BS group) and proximal covered stent grafting without distal bare stenting (non-BS group).

METHODS

The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases and key references were searched up to January 26, 2019. Predefined outcomes of interest were mortality, morbidity, and postoperative assessment of aortic remodeling. We pooled risk ratios (RRs) of the outcomes of interest using fixed effects model or random effects model.

RESULTS

Overall, eight observational studies involving 914 patients were included. There were no significant differences in overall aorta-related mortality (RR, 0.54; confidence interval [CI], 0.24-1.24; P = .15), complete thoracic false lumen (FL) thrombosis rate (RR, 1.23; CI, 0.83-1.81; P = .30), or complete abdominal FL thrombosis rate (RR, 1.96; CI, 0.68-5.69; P = .21) between the BS group and the non-BS group. The BS group had a lower rate of partial thoracic FL thrombosis (RR, 0.40; CI, 0.25-0.65; P = .0002), a lower stent graft-induced new entry rate (RR, 0.08; CI, 0.02-0.41; P = .003), and a lower reintervention rate (RR, 0.42; CI, 0.26-0.69; P = .0005).

CONCLUSIONS

Combined proximal covered stent grafting with distal adjunctive bare stenting had the potential to reduce the partial thoracic FL thrombosis rate and the rates of stent graft-induced new entry and reintervention but was not associated with lower aorta-related mortality or the complete FL thrombosis rate. Further research with a stricter methodology is needed.

Repeat Surgery in Chronic Aortic Dissection: A New Technique without Touching the Native Aorta

BACKGROUND

 Repeat surgery of the chronically dissected aorta following repair of a Type-A acute aortic dissection (AAD) still represents a challenge. The proposed surgical options are as follows: (1) staged procedure with elephant trunk (ET) technique, (2) traditional frozen elephant trunk (FET) intervention, and (3) beating heart cerebral vessel debranching followed by thoracic endovascular aortic repair (TEVAR). However, a marked enlargement of the proximal descending thoracic aorta might make it difficult to perform FET/ET intervention. Furthermore, because in conventional surgery for AAD, a prosthetic graft replacement is generally limited to the ascending aorta, and in repeat surgery, this short Dacron graft rarely provides enough room to allow a beating heart cerebral vessel debranching and obtaining a reliable landing zone for the implantation of a firmly anchored stent graft.

METHODS

 We retrospectively reviewed all the five consecutive patients treated in our institution, between 2014 and 2017, for chronic aortic dissection after successful surgical treatment of acute Type-A aortic dissection with graft replacement limited to the ascending aorta. The five patients underwent repair utilizing a modified FET technique with total aortic arch and upper descending aorta exclusion without touching the native dissected aorta.

RESULTS

 No early- or midterm mortality was observed. Mean time interval between the initial and the reoperative procedure was 26 months (range, 3-80 months). No patient had a minor/major neurologic event. Mean circulatory arrest time was 16 minutes (range, 11-25 minutes). Mean follow-up time was 22 months (range, 9-42 months).

CONCLUSIONS

 We report our initial experience with a modified FET technique realized by anastomosing the stent graft with the previously implanted ascending aortic graft in Hishimaru's zone 0 and by rerouting all cerebral vessels without "touching" the native chronically dissected aorta. A larger number of patients and a longer follow-up will be required to confirm these initial encouraging results.

Surgical outcomes of aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection

OBJECTIVES

To evaluate the surgical outcomes of aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection.

METHODS

Between 2008 and 2015, a total of 300 patients with acute Type A aortic dissection underwent emergency surgery, consisting of 271 hemiarch repairs and 29 total aortic arch replacements, using transapical cannulation and the adventitial inversion technique at a distal anastomosis. The mean follow-up periods were 31.7 ± 25.2 months. Overall, 18% (54/300) of the patients were octogenarians, and 21.7% (65/300) had cardiac tamponade; 25% (75/300) had preoperative malperfusion.

RESULTS

The in-hospital and 30-day mortality rates were 8.3% (25/300) and 6.7% (20/300), respectively. The 30-day mortality rate was 2.7% (6/225) among patients without preoperative malperfusion and 18.7% (14/75) among patients with malperfusion (P < 0.0001), 7.4% (4/54) among octogenarians and 6.5% (16/246) among patients aged less than 80 years (P = 0.81), and 6.3% (17/271) among patients treated with hemiarch repair and 10.3% (3/29) among patients treated with total aortic arch replacement (P = 0.403). Preoperative malperfusion was an independent predictor of perioperative mortality in a multivariable analysis. During the follow-up period, distal reintervention was performed in 11% (33/300) of the patients. The rates of freedom from reintervention at 1, 3 and 5 years were 95.9%, 88.9% and 80.0%, respectively. The overall survival rates at 1, 3 and 5 years were 88.7%, 86.7% and 82.0%, respectively. The in-hospital mortality rate for elective reintervention was 3.0% (1/33).

CONCLUSIONS

Aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection provides good early and mid-term results. The safety of elective distal reintervention can be guaranteed. To obtain better operative outcomes, effective treatment for cases with malperfusion is mandatory.

Distal Neo-Neck Formation for Chronic Type B Dissection: False Lumen Closure After TEVAR

OBJECTIVES:

Patients with chronic aortic dissection often require repeat interventions due to enlargement of the pressurized false lumen or disseminated intravascular coagulation even after additional thoracic endovascular aortic repair (TEVAR) to occlude the entry tear. Residual false lumen flow can persist even after performing the candy-plug technique or branched stent-graft placement in some cases. We have devised a new method for false lumen closure.

METHODS:

From December 2010 to May 2017, 5 patients (mean age: 57 [13] years, range: 43-77 years) with chronic dissection at the aortic arch and descending aorta, who underwent initial TEVAR, required additional treatment. Using an open surgical approach, the endograft was fixed with an outer felt under cardiopulmonary bypass after the endograft with stent was expanded by fenestration. The false lumen was closed using this procedure, and the aortotomy was repaired by direct closure in 2 cases and by graft replacement in 3 cases.

RESULTS:

No major operative complications occurred, such as respiratory failure or paraplegia. Postoperative enhanced computed tomography (CT) images showed that the false lumen flow disappeared in all cases. All patients were discharged under normal conditions. They were all followed up and their CT did not indicate any complications for a mean of 33.6 (20.3) months.

CONCLUSIONS:

Our combined procedure was effective and provided a higher success rate compared with endovascular therapy alone. This staged treatment approach, using a combination of TEVAR and false lumen closure, is less invasive compared with open surgery alone and may represent a valid treatment option for chronic type B dissection.

Frozen elephant trunk and arch endografts for chronic thoracoabdominal aortic dissections

Chronic aortic dissecting aneurysms (TAAD) presenting after acute Stanford type A or B dissection includes both arch and/or thoracoabdominal aortic aneurysms (TAAA). Approximately 60% of patients who survive surgical treatment of acute type A aortic dissections will require another aortic procedure. Similarly, more than 70% of patients with chronic type B aortic dissections will experience false lumen dilation at 5-year follow-up, often requiring intervention. Open or hybrid aortic repairs of complex TAAD involving the arch and the TAAA are very demanding procedures for both patients and clinicians. Open surgery remains the first line therapy in fit patients. Recent development of branched arch devices has offered an alternative option for high-risk patients. Technical challenges associated with the endovascular management of these complex aneurysms include proximal sealing zone often located in the aortic arch or the ascending aorta, narrow true lumen working space, and aortic branch perfusion by either the true or false lumen, or both. Recent studies have reported encouraging results with endovascular treatment of these complex dissecting aneurysms, especially following open ascending aortic repair. The aim of this review was to describe the available strategies for arch repair in the setting of a chronic TAAD and to determine the subset of patients that can benefit from of a totally endovascular approach.

Chronic type B "residual" after type A: what I would do?

"The major goal of surgery for acute type A aortic dissection is to have an alive patient." This motto still remains the most important directive. However, also depending onto the extent of the underlying pathology and consecutively depending onto the extent of primary surgery, there is and will be need for additional classical surgical or interventional treatment sooner or later during follow-up in a substantial number of patients having had surgery for acute type A aortic dissection. This article shall guide the interested reader through the underlying mechanisms as well as treatment options in patients with chronic type B "residual" after type A repair and shall finally suggest preventive strategies to reduce the occurrence of this pathology to a minimum.

Re-interventions on the thoracic and thoracoabdominal aorta in patients with Marfan syndrome

The advent of multi-gene panel genetic testing and the discovery of new syndromic and non-syndromic forms of connective tissue disorders have established thoracic aortic aneurysms as a genetically mediated disease. Surgical results in patients with Marfan syndrome (MFS) provide an important benchmark for this patient population. Prophylactic aortic root surgery prevents acute dissection and has contributed to the improved survival of MFS patients. In the majority of patients, re-interventions are driven by a history of dissection. Patients undergoing elective root repair have a low risk for re-interventions on the root itself. Experienced centers have results after valve-sparing procedures at 10 years comparable with those seen after a modified Bentall procedure. In patients where only the ascending aorta was replaced during the initial surgery, re-intervention rates are high as the root continues to dilate. The fate of the aortic arch in MFS patients presenting with dissection is strongly correlated with the extent of the initial surgery. Not replacing the entire ascending aorta and proximal aortic arch results in a high rate of re-interventions. Nevertheless, the additional burden of replacing the entire aortic arch during emergent proximal repair is not very well defined and makes comparisons with patients undergoing elective arch replacement difficult. Interestingly, replacing the entire aortic arch during initial surgery for acute dissection does not protect from re-interventions on downstream aortic segments. MFS patients suffering from type B dissection have a high risk for re-interventions ultimately leading up to replacement of the entire thoracoabdominal aorta even if the dissection was deemed uncomplicated by conventional criteria. While current guidelines do not recommend the implantation of stent grafts in MFS patients, implantation of a frozen-elephant-trunk to create a stable proximal landing zone for future endovascular or open procedures has emerged as a means to address aortic arch and descending aortic pathologies.

Regional Practice Patterns and Outcomes of Surgery for Acute Type A Aortic Dissection

BACKGROUND

The surgical management of acute type A aortic dissection is evolving, and many aortic centers of excellence are reporting superior outcomes. We hypothesize that similar trends exist in a multiinstitutional regional consortium.

METHODS

Records for 884 consecutive patients who underwent aortic operations (2003 to 2015) for acute type A aortic dissection were extracted from a regional The Society of Thoracic Surgeons database. Patients were stratified into three equal operative eras. Differences in outcomes and risk factors for morbidity and mortality were determined.

RESULTS

Surgical procedures for type A aortic dissection are increasing in extent and complexity. Aortic root repair was performed in 16% of early era cases compared with 67% currently (p < 0.0001). Similarly, aortic arch repair increased from 27% to 37% cases (p < 0.0001). Cerebral perfusion is currently used in 85% of circulatory arrest cases, most frequently antegrade (57%). Total circulatory arrest times increased (29 minutes vs 31 minutes vs 36 minutes; p = 0.005), but times without cerebral perfusion were stable (12 minutes vs 6 minutes; p = 0.68). Although the operative mortality rate remained stable at 18.9% during the 3 operative eras, there were significant decreases in pneumonia and reoperations (p < 0.05). Predictors of operative mortality and major morbidity are age (odds ratio [OR], 1.04; p < 0.0001), previous stroke (OR, 2.09; p = 0.03), and elevated creatinine (OR, 1.31; p = 0.01). Importantly, the extent of aortic operation did not increase risk for morbidity or mortality.

CONCLUSIONS

Operative morbidity and mortality remain significant for type A aortic dissection, but lower than historical outcomes. The extent of aortic surgery has increased, resulting in adaptive cerebral protection changes in contemporary "real-world" practice.

Transcatheter Closure of Anastomotic Leakage After Aortic Surgery for Type A Dissection with the Amplatzer Duct Occluder II

Aortic anastomotic leakage is an inevitable but intractable complication of surgery for type A dissection. The treatment has been mostly surgical with a high rate of morbidity and mortality. We describe a 54-year-old patient with anastomotic leakage after his secondary surgery for type A dissection. The leakage located at the proximal site of the stent-graft and fed the false lumen. We have performed a complete occlusion by transcatheter closure using Amplatzer Duct Occluder II.

Early outcomes in re-do operation after acute type A aortic dissection: results from the multicenter REAAD database

This study provides early results of re-operations after the prior surgical treatment of acute type A aortic dissection (AAD) and identifies risk factors for mortality. Between May 2003 and January 2014, 117 aortic re-operations after an initial operation for AAD (a mean time from the first procedure was 3.98 years, with a range of 0.1-20.87 years) were performed in 110 patients (a mean age of 59.8 ± 12.6 years) in seven European institutions. The re-operation was indicated due to a proximal aortic pathology in ninety cases: twenty aortic root aneurysms, seventeen root re-dissections, twenty-seven aortic valve insufficiencies and twenty-six proximal anastomotic pseudoaneurysms. In fifty-eight cases, repetitive surgical treatment was subscripted because of distal aortic pathology: eighteen arch re-dissections, fifteen arch dilation and twenty-five anastomotic pseudoaneurysms. Surgical procedures comprised a total of seventy-one isolated proximals, thirty-one isolated distals and fifteen combined interventions. In-hospital mortality was 19.6 % (twenty-three patients); 11.1 % in patients with elective/urgent indication and 66.6 % in emergency cases. Mortality rates for isolated proximal, distal and combined operations regardless of the emergency setting were 14.1 % (10 pts.), 25.8 % (8 pts.) and 33.3 % (5 pts.), respectively. The causes of death were cardiac in eight, neurological in three, MOF in five, sepsis in two, bleeding in three and lung failure in two patients. A multivariate logistic regression analysis revealed that risk factors for mortality included previous distal procedure (p = 0.04), new distal procedure (p = 0.018) and emergency operation (p < 0.001). New proximal procedures were not found to be risk factors for early mortality (p = 0.15). This multicenter experience shows that the outcome of REAAD is highly dependent on the localization and extension of aortic pathology and the need for emergency treatment. Surgery in an emergency setting and distal re-do operations after previous AAD remain a surgical challenge, while proximal aortic re-operations show a lower mortality rate. Foresighted decision-making is needed in cases of AAD repair, as the results are essential preconditions for further surgical interventions.

Successful interventional management of postoperative hemorrhage in total arch replacement of type A aortic dissection

We reported a 48-year-old male patient with postoperative hemorrhage. Given his frailty, emergent interventional procedures were successfully performed and the end of the left subclavian artery was embolized by four coils. Our report provided a new therapeutic approach regarding the frail patients presenting postoperative hemorrhage.

Surgical management and outcomes of type A dissection-the Mayo Clinic experience

BACKGROUND

Type A aortic dissection (TAAD) is a complex cardiovascular disease that is associated with high perioperative morbidity and mortality. The most effective approach is still being debated-such as the best cannulation technique, and conservative versus extensive initial surgery. We reviewed our experience over the last 20 years and examined for variables that correlated with observed outcomes.

METHODS

All patients who underwent TAAD repair were reviewed. Chi-Square tests, Fisher Exact tests and Wilcoxon tests were performed where appropriate. Survival and freedom from reoperations were analyzed with the Kaplan-Meier actuarial method.

RESULTS

Acute TAAD was associated with a higher incidence of permanent stroke (P=0.010), renal failure (P=0.025), prolonged mechanical ventilator support (P=0.004), higher operative mortality (P=0.039) and higher 30-day mortality (P=0.003) compared to chronic TAAD. There was a trend towards higher risk for transient neurologic events among patients who were reoperated on (P=0.057). Extensive proximal repair led to longer perfusion and cross clamp times (P<0.001) and the need for temporary mechanical support post-operatively (P=0.011). More patients that had extensive distal repair underwent circulatory arrest (P=0.009) with no significant differences in the incidence of peri-operative complications, early, middle and long-term survival compared to the conservative management group. Overall survival in our series was 66.73% and 46.30% at 5 and 10 years respectively (median survival time: 9.38 years). There was a significant improvement in operative mortality (P=0.002) and 30-day mortality (P=0.033) in the second decade of our study.

DISCUSSION

TAAD is a complex disease with several options for its surgical management. Each technique has its own advantages and complications and surgical management should be individualized depending on the clinical presentation. We propose our present approach to maximize benefits in both the short and long term.

Complex Reoperation for Late Complications After Acute Type A Aortic Dissection Surgery

The correct management of acute Type A dissection continues to be a challenge. The primary goal is to save the patient´s life. However, the decision regarding the surgical approach determines possible later complications. We present the case of a 59-year-old female patient with a past history of emergent surgery for acute Type A dissection treated by supracoronary ascending and aortic valve replacement 19 years previously. Later, in a second endovascular approach, the descending aorta was treated by a thoracic endoprosthesis. During follow-up a dilated aortic root and a Type I endoleak were observed, and complex reoperation was required. We performed a total aortic arch replacement with a 4-branched graft and a complete aortic root replacement using the Cabrol technique for the reinsertion of the coronary arteries. The mechanical aortic normally functioning valve was preserved. The patient was discharged 30 days postoperatively.

Surgical Strategy and Outcome for Aortic Root in Patients Undergoing Repair of Acute Type A Aortic Dissection

BACKGROUND

This study evaluated the relevance of our indication of aortic root operations for acute type A aortic dissection and compared early and long-term outcomes of emergency type A aortic dissection operations between patients who underwent aortic root operations and those who did not.

METHODS

We retrospectively reviewed 316 consecutive patients who underwent emergency aortic operations for acute type A aortic dissection between January 2009 and September 2013. We performed simultaneous aortic root operations when the aortic root diameter was greater than 45 mm or an intimal tear was present in the aortic root, or both. After this indication, we performed aortic repair involving the aortic root in 40 patients (aortic root replacement [ARR] group, 12.7%) and not involving the aortic root in 276 patients (non-ARR group, 87.3%). We analyzed early and long-term outcomes, including late aortic root events.

RESULTS

In-hospital mortality was 12.5% (5 of 40) in the ARR group and 4.7% (13 of 276) in non-ARR group (p = 0.05). Overall survival at 3 and 5 years was 84.8% and 84.8%, respectively in ARR group and was 91.9% and 91.9%, respectively, in the non-ARR group (p = 0.078). Late aortic root events, defined as aortic root dilatation (≥ 3 mm/y), reoperation of the aortic root, aortic regurgitation (moderate or higher), and pseudoaneurysm, were observed in no patients in the ARR group and in 32 patients (11.6%) in the non-ARR group (p = 0.029). In the non-AAR group, dissection of 2 or more aortic sinuses was the only independent predictor of a late aortic root event (hazard ratio, 2.20; 95% confidence interval, 1.08 to 4.61; p = 0.03).

CONCLUSIONS

Simultaneous aortic root operations significantly reduced the incidence of late aortic root events. The dissection of 2 or more sinuses of Valsalva was associated with a late aortic root event in patients who did not undergo aortic root operations.

Risk-reducing strategies for repair of complex ascending aortic false aneurysms

Late presentation of aortic false aneurysm following repair of acute type A aortic dissection occurs in 10% to 24% of cases. This condition is associated with high mortality if left untreated. Herein we describe a combination of surgical strategies that we believe may be used effectively to reduce the surgical risk of these complex operations.